Northeastern Health System Sequoyah

“Quality assessment/performance improvement CFR(s): 484.65 Condition of participation: Quality assessment and performance improvement (QAPI). The HHA must develop, implement, evaluate, and maintain an effective, ongoing, HHA-wide, data-driven QAPI program. The HHA’s governing body must ensure that the program reflects the complexity of its organization and services; involves all HHA services (including those services provided under contract or arrangement); focuses on indicators related to improved outcomes, including the use of emergent care services, hospital admissions and re-admissions; and takes actions that address the HHA’s performance across the spectrum of care, including the prevention and reduction of medical errors. The HHA must maintain documentary evidence of its QAPI program and be able to demonstrate its operation to CMS. This Condition is not met as evidenced by: Based on record review and interviews, the agency failed to ensure evidence of a patient centered QAPI Program in calendar years 2023, 2024 and 01/01/25 to 06/24/25 for all patients and employees. The failed practice had the potential to place all patients and employees at risk for insufficient self-monitoring and efforts to improve care, services and operations. See tag G642. Based on record review and interviews, the agency failed to ensure utilization of QAPI quality indicator data in calendar years 2023, 2024 and 01/01/25 to 06/24/25 for all patients and employees. The failed practice had the potential to place all patients at risk of repeated agency mishaps, ineffective management of care and poor quality of care. See Tag #G644. Based on record review and interview, the agency failed to ensure conduction of patient centered QAPI program activities included self-monitoring efforts that identified and evaluated outcomes to improve care, services, and operations in calendar years 2023, 2024 and 01/01/25 to 06/24/25 for all patients and employees. The failed practice had the potential to place all patients and employees at risk loss of opportunity to identify problems and loss of ability to correct problems that threaten the health and safety of all patients and staff. See tag #G646. Based on record review and interviews, the agency failed to ensure performance improvement projects for the agency in calendar years 2023 and 2024 for all patients and three employees. The failed practice had the potential to place the agency, its patients and all employees at risk for stagnated efforts for improvement because of unidentified problematic clinical, administrative, infection control or personnel problems. See Tag #G658. Based on record review and interview, the agency failed to ensure governing body oversite of conduction of a patient centered QAPI program in calendar years 2023 and 2024 for all patients and employees. The failed practice had the potential to place all patients and employees at risk for insufficient governing body oversite of agency services and operations. See Tag #G660. .”

“Organization and administration of services CFR(s): 484.105 Condition of participation: Organization and administration of services. The HHA must organize, manage, and administer its resources to attain and maintain the highest practicable functional capacity, including providing optimal care to achieve the goals and outcomes identified in the patient’s plan of care, for each patient’s medical, nursing, and rehabilitative needs. The HHA must assure that administrative and supervisory functions are not delegated to another agency or organization, and all services not furnished directly are monitored and controlled. The HHA must set forth, in writing, its organizational structure, including lines of authority, and services furnished. This Condition is not met as evidenced by: Based on record review and interview, the agency failed to ensure governing body oversite of the agency for program evaluation, operating budget, and capital expenditure plan in calendar years 2023 and 2024 for all patients and employees. The failed practice had the potential to impact on the care and services provided by the agency in the communities that it serves. See tag G942. Based on record review and interview, the agency failed to ensure governing body appointment of the administrator for the agency in calendar years 2023 and 2024 and 01/01/25 to 06/24/25 for all patients and staff. The failed practice had the potential to effect day-to-day operational oversite responsibilities of the agency, impacting the services its patients received. See tag G946. Based on record review and interview, the agency failed to ensure governing body appointment of a supervising nurse for the agency in calendar years 2023 and 2024 and 01/01/25 to 06/24/25 for all patients and employees. The failed practice had the potential to effect the services provided by the agency and the subsequent care outcomes of its patients and to provide adequate clinical supervisory oversite of its staff. See tag G958. .”

“Names and Contact Information CFR(s): 484.102(c)(1) §403.748(c)(1), §416.54(c)(1), §418.113(c)(1), §441.184(c)(1), §460.84(c)(1), §482.15(c)(1), §483.73(c)(1), §483.475(c)(1), §484.102(c)(1), §485.68(c)(1), §485.542(c)(1), §485.625(c)(1), §485.727(c)(1), §485.920(c)(1), §486.360(c)(1), §491.12(c)(1), §494.62(c)(1). [(c) The [facility must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following:] (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians (iv) Other [facilities]. (v) Volunteers. *[For Hospitals at §482.15(c) and CAHs at §485.625(c)] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians (iv) Other [hospitals and CAHs]. (v) Volunteers. *[For RNHCIs at §403.748(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Next of kin, guardian, or custodian. (iv) Other RNHCIs. (v) Volunteers. *[For ASCs at §416.45(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians. (iv) Volunteers. *[For Hospices at §418.113(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Hospice employees. (ii) Entities providing services under arrangement. (iii) Patients’ physicians. (iv) Other hospices. *[For HHAs at §484.102(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians. (iv) Volunteers. *[For OPOs at §486.360(c):] The communication plan must include all of the following: (2) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Volunteers. (iv) Other OPOs. (v) Transplant and donor hospitals in the OPO’s Donation Service Area (DSA). This Standard is not met as evidenced by: Based on record review and interview, the agency failed to ensure an Emergency Preparedness Communication Plan included current employee contact information for the agency for nine (Patients #1, 2, 3, 4, 5, 6, 7, 8 and #9) of nine patients and seven employees. Findings: A review of administrative records showed an Emergency Preparedness Communication Plan with former employee contact information and had no current employee contact information for the agency. On 06/25/25 at 1:50 p.m., Staff A stated the Emergency Preparedness Communication Plan was not updated to include contact information for current employees of the agency.”

“Program scope CFR(s): 484.65(a)(1),(2) Standard: Program scope. (1) The program must at least be capable of showing measurable improvement in indicators for which there is evidence that improvement in those indicators will improve health outcomes, patient safety, and quality of care. (2) The HHA must measure, analyze, and track quality indicators, including adverse patient events, and other aspects of performance that enable the HHA to assess processes of care, HHA services, and operations. This Standard is not met as evidenced by: Based on record review and interviews, the agency failed to ensure evidence of a patient centered QAPI Program in calendar years 2023, 2024 and 01/01/25 to 06/24/25 for all patients and employees. The failed practice had the potential to place all patients and employees at risk for insufficient self-monitoring and efforts to improve care, services and operations. Findings: A review of QAPI records showed no QAPI program improvement quarterly meeting activity, measurements, analysis, tracking or evaluation of data by the agency in calendar years 2023, 2024 and 01/01/25 to 06/24/25. On 06/25/25 at 2:40 p.m., Staff A stated: 1. All the QAPI program documentation was provided. 2. There were no QAPI program meeting minutes or documented activities for calendar years 2023 and 2024 and 01/01/25 to 06/24/25. 3. We failed at QA.”

“Program data CFR(s): 484.65(b)(1),(2),(3) Standard: Program data. (1) The program must utilize quality indicator data, including measures derived from OASIS, where applicable, and other relevant data, in the design of its program. (2) The HHA must use the data collected to- (i) Monitor the effectiveness and safety of services and quality of care; and (ii) Identify opportunities for improvement. (3) The frequency and detail of the data collection must be approved by the HHA’s governing body. This Standard is not met as evidenced by: Based on record review and interviews, the agency failed to ensure utilization of QAPI quality indicator data in calendar years 2023, 2024 and 01/01/25 to 06/24/25 for all patients and employees. The failed practice had the potential to place all patients at risk of repeated agency mishaps, ineffective management of care and poor quality of care. Findings: A review of QAPI records showed no quality indicator data collection sources were utilized in the analysis and reporting of data in the agency’s QAPI Program in calendar years 2023, 2024 and 01/01/25 to 06/24/25. On 06/25/25 at 2:40 p.m., Staff A stated: 1. All the QAPI program documentation was provided. 2. There were no QAPI program meeting minutes or documented activities for calendar years 2023 and 2024 and 01/01/25 to 06/24/25. 3. We failed at QA.”

“Program activities CFR(s): 484.65(c) (1) The HHA’s performance improvement activities must— (i) Focus on high risk, high volume, or problem-prone areas; (ii) Consider incidence, prevalence, and severity of problems in those areas; and (iii) Lead to an immediate correction of any identified problem that directly or potentially threaten the health and safety of patients. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to ensure conduction of patient centered QAPI program activities included self-monitoring efforts that identified and evaluated outcomes to improve care, services, and operations in calendar years 2023, 2024 and 01/01/25 to 06/24/25 for all patients and employees. The failed practice had the potential to place all patients and employees at risk loss of opportunity to identify problems and loss of ability to correct problems that threaten the health and safety of all patients and staff. Findings: A review of QAPI records showed no patient centered QAPI Program activities that included self-monitoring efforts that identified and evaluated outcomes to improve care, services, and operations in calendar years 2023, 2024 and 01/01/25 to 06/24/25. On 06/25/25 at 2:40 p.m., Staff A stated: 1. All the QAPI program documentation was provided. 2. There were no QAPI program meeting minutes or documented activities for calendar years 2023 and 2024 and 01/01/25 to 06/24/25. 3. We failed at QA.”

“Performance improvement projects CFR(s): 484.65(d)(1)(2) Standard: Performance improvement projects. Beginning July 13, 2018 HHAs must conduct performance improvement projects. (1) The number and scope of distinct improvement projects conducted annually must reflect the scope, complexity, and past performance of the HHA’s services and operations. (2) The HHA must document the quality improvement projects undertaken, the reasons for conducting these projects, and the measurable progress achieved on these projects. This Standard is not met as evidenced by: Based on record review and interviews, the agency failed to ensure performance improvement projects for the agency in calendar years 2023 and 2024 for all patients and three employees. The failed practice had the potential to place the agency, its patients and all employees at risk for stagnated efforts for improvement because of unidentified problematic clinical, administrative, infection control or personnel problems. Findings: A review of QAPI Program records showed no performance improvement project goals, collection, analysis and review of related data and follow up monitoring and reporting of the identified performance improvement project problem in calendar years 2023 and 2024. On 06/25/25 at 2:40 p.m., Staff A stated: 1. All the QAPI program documentation was provided. 2. There were no QAPI program meeting minutes or documented activities for calendar years 2023 and 2024 and 01/01/25 to 06/24/25. 3. We failed at QA.”

“Executive responsibilities for QAPI CFR(s): 484.65(e)(1)(2)(3)(4) Standard: Executive responsibilities. The HHA’s governing body is responsible for ensuring the following: (1) That an ongoing program for quality improvement and patient safety is defined, implemented, and maintained; (2) That the HHA-wide quality assessment and performance improvement efforts address priorities for improved quality of care and patient safety, and that all improvement actions are evaluated for effectiveness; (3) That clear expectations for patient safety are established, implemented, and maintained; and (4) That any findings of fraud or waste are appropriately addressed. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to ensure governing body oversite of conduction of a patient centered QAPI program in calendar years 2023 and 2024 for all patients and employees. The failed practice had the potential to place all patients and employees at risk for insufficient governing body oversite of agency services and operations. Findings: A review of governing body meeting minute records showed no governing body oversite in the conduction of a patient centered QAPI program for calendar years 2023 and 2024. On 06/25/25 at 2:40 p.m., Staff A stated there were no QAPI program meeting minutes or documented activities for calendar years 2023 and 2024 to report to the governing body.”

“Infection control CFR(s): 484.70(b)(1)(2) Standard: Control. The HHA must maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HHA’s quality assessment and performance improvement (QAPI) program. The infection control program must include: (1) A method for identifying infectious and communicable disease problems; and (2) A plan for the appropriate actions that are expected to result in improvement and disease prevention. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to ensure infection control program surveillance data was included in QAPI program activities in calendar years 2023, 2024 and 01/01/25 to 06/24/25 for all patients and employees. Findings: A review of QAPI records for calendar years 2023, 2024 and 01/01/25 to 06/24/25 were requested for review. No records were provided that showed infection control surveillance data. On 06/25/25 at 2:40 p.m., Staff A stated: 1. All QAPI program documentation was provided. 2. There were no QAPI program meeting minutes or documented activities for calendar years 2023 and 2024 and 01/01/25 to 06/24/25.”

“Home health aide assignments and duties CFR(s): 484.80(g)(1) Standard: Home health aide assignments and duties. Home health aides are assigned to a specific patient by a registered nurse or other appropriate skilled professional, with written patient care instructions for a home health aide prepared by that registered nurse or other appropriate skilled professional (that is, physical therapist, speech-language pathologist, or occupational therapist). This Standard is not met as evidenced by: Based on record review and interview, the agency failed to ensure a home health aide care plan was reviewed and updated for the certification period for three (Patients #3, 5 and #9) of nine patients. Findings: Patient #3 A review of the clinical record showed no documented home health aide care plan or receipt of assignment by the CHHA for the episode of 05/04/25 through 07/02/25. The clinical record showed home health aide visits were completed on 05/05/25, 05/08/25, 05/12/25, 05/15/25, 05/19/25, 05/22/25, 05/29/25, 06/02/25, 06/05/25, 06/09/25, 06/12/25, 06/16/25 and on 06/19/25. On 06/26/25 at 12:46 p.m., Staff B stated the clinical record showed no home health aide care plan. Patient #5 A review of the clinical record showed no documented home health aide care plan or receipt of assignment by the CHHA for the episode of 05/13/25 through 07/11/25. The clinical record showed home health aide visits were completed on 05/13/25, 05/20/25, 05/27/25, 06/03/25, 06/10/25 and on 06/17/25. On 06/26/25 at 1:00 p.m., Staff B stated the clinical record showed no home health aide care plan. Patient #9 A review of the clinical record showed no documented home health aide care plan or receipt of assignment by the CHHA for the episode of 05/15/25 through 07/13/25. The clinical record showed home health aide visits were completed on 05/16/25, 05/20/25, 05/23/25, 05/27/25, 05/29/25, 06/03/25, 06/05/25, 06/10/25, 06/13/25, 06/17/25 and on 06/20/25. On 06/26/25 at 1:25 p.m., Staff B stated the clinical record showed no home health aide care plan.”

“Governing body CFR(s): 484.105(a) Standard: Governing body. A governing body (or designated persons so functioning) must assume full legal authority and responsibility for the agency’s overall management and operation, the provision of all home health services, fiscal operations, review of the agency’s budget and its operational plans, and its quality assessment and performance improvement program. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to ensure governing body oversite of the agency for program evaluation, operating budget, and capital expenditure plan in calendar years 2023 and 2024 for all patients and employees. The failed practice had the potential to impact on the care and services provided by the agency in the communities that it serves. Findings: A review of governing body records showed no governing body oversite of the agency program evaluation, operating budget, and capital expenditure plan in calendar years 2023 and 2024. On 06/26/25 at 1:45 p.m., Staff A stated governing body meeting minutes showed no governing body oversite of the agency program evaluation, operating budget, and capital expenditure plan in calendar years 2023 and 2024.”

“Clinical manager CFR(s): 484.105(c) Standard: Clinical manager. One or more qualified individuals must provide oversight of all patient care services and personnel. Oversight must include the following-- This Standard is not met as evidenced by: Based on record review and interview, the agency failed to ensure governing body appointment of a supervising nurse for the agency in calendar years 2023 and 2024 and 01/01/25 to 06/24/25 for all patients and employees. The failed practice had the potential to effect the services provided by the agency and the subsequent care outcomes of its patients and to provide adequate clinical supervisory oversite of its staff. Findings: A review of administrative governing body records showed no designated supervising nurse for the agency in calendar years 2023 and 2024 and 01/01/25 to 06/24/25. On 06/26/25 at 1:45 p.m., Staff A stated governing body meeting minutes did not show appointment of the administrator for the agency in calendar years 2023 and 2024 and 01/01/25 to 06/24/25.”

“HHA administrator contact information CFR(s): 484.50(a)(1)(ii) (ii) Contact information for the HHA administrator, including the administrator’s name, business address, and business phone number in order to receive complaints. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the administrator’s name and contact information was a part of the admission packet information provided at a patient’s SOC for nine (Patients #1, 2, 3, 4, 5, 6, 7, 8, and #9) of nine patients. Findings: A review of administrative records (start of care patient information packet) identified contact information for the prior administrator who left the agency on or about 05/01/25. On 06/26/25 at 1:45 p.m., Staff A stated the contact information for the current administrator had not been updated in the patient information packet.”

“HHA can no longer meet the patient’s needs CFR(s): 484.50(d)(1) The transfer or discharge is necessary for the patient’s welfare because the HHA and the physician or allowed practitioner, who is responsible for the home health plan of care agree that the HHA can no longer meet the patient’s needs, based on the patient’s acuity. The HHA must arrange a safe and appropriate transfer to other care entities when the needs of the patient exceed the HHA’s capabilities; This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure: 1. Attempted resolution of non-compliance and refusal of care for two (Patients #6 and #8) of nine patients. 2. Notification to the physician prior to discharge for three (Patients #6, 7 and #8) of nine patients. Findings: Patient #6 A review of the clinical records showed the patient was discharged from the agency on 02/24/25 for non-compliance. The clinical record showed no POC from 02/18/25 to 02/24/25. The clinical record identified no issues of non-compliance, showed no communication or coordination of care attempts with the patient to resolve issues of the non-compliance, and showed no communication or coordination of care with the ordering medical provider to notify the patient was being discharged from home care services. On 06/26/25 at 1:05 p.m., Staff B stated: 1. The nurse did not identify or document issues of non-compliance by the patient or attempts to resolve issues of non-compliance. 2. The SN did not communicate with the ordering medical provider that the patient was being discharged from the agency prior to the patient’s discharge from HHA services on 02/24/25. Patient #7 A review of the clinical records showed the patient was discharged from the agency on 04/16/25 to hospice provider services. The clinical record showed no communication or coordination of care attempts with the hospice and showed no communication or coordination of care with the ordering medical provider to notify the patient was being discharged from home care services. On 06/26/25 at 1:10 p.m., Staff B stated the nurse did not communicate with the ordering medical provider that the patient was being discharged from the agency to hospice services prior to the patient’s discharge from HHA services on 04/16/25. Patient #8 A review of the clinical records showed the patient was discharged from the agency on 05/26/25 for refusal of care. The clinical record showed a POC from 03/28/25 to 05/26/25 for SN visit frequency of weekly to assess and instruct health conditions and to perform catheter change treatment intervention monthly for urinary management. The clinical record identified no issues of refusal of care, showed no communication or coordination of care attempts with the patient to resolve issues of the refusal of care, and showed no communication or coordination of care with the ordering medical provider, to notify the patient was being discharged from home care services. On 06/26/25 at 1:15 p.m., Staff B stated: 1. The nurse did not identify or document issues of refusal of care by the patient or attempts to resolve issues related to refusal of care. 2. The SN did not communicate with the ordering medical provider that the patient was being discharged from the agency prior to the patient’s discharge from HHA services on 05/26/25.”

“Patient/payer will no longer pay for services CFR(s): 484.50(d)(2) The patient or payer will no longer pay for the services provided by the HHA; This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure advance beneficiary notices prior to discharge from agency services were provided to two (Patients #6 and 8) of nine patients. Findings: Patient #6 A review of the clinical record showed no advance notice of discharge or home health change of care notice prior to discharge from the agency on 02/24/25 for non-compliance. Patient #8 A review of the clinical record showed no advance notice of discharge or home health change of care notice prior to discharge from the agency on 05/26/25 for refusal of care. On 06/26/25 at 1:05 p.m., Staff B stated there were no ABN notices in the clinical records for patients #6 and #8 prior to being discharged from the agency.”

“Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient’s mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient’s risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure individualized patient POC included: Removal of outdated PT evaluation and treatment orders were removed for one (Patient #1) of nine patients.SN interventions and goals for two (Patients #3 and #9) of nine patients.An individualized patient POC for two (Patients #4 and #7) of nine patients. Catheter treatment/intervention last changed and/or treatment due date for one (Patient #8) of nine patients. SN and CHHA goals for one (Patient #9) of nine patients. Findings: Patient #1 A review of the POC dated 05/11/25 to 07/09/25 showed orders for PT to evaluate and treat the week of 11/17/24 (174 days before the start of the certification period). The clinical record showed no communications or physician orders for PT evaluation from 05/11/25 to 06/26/25. On 06/26/25 at 12:40 p.m., Staff B stated the nurse should have reviewed, revised and updated the POC at the time of the recertification assessment visit prior to 05/11/25. Patient #3 A review of the POC dated 05/04/25 to 07/02/25 showed orders for SN visit frequency of one time a week for eight weeks to assess health conditions and home health aide visit frequency of two times a week for nine weeks. The POC showed no SN or CHHA interventions and goals. The clinical record showed no physician notifications or changes in orders. On 06/26/25 at 12:46 p.m., Staff B stated the POC should have SN and home health aide interventions and goals. Patient #4 A review of the clinical record showed no POC (physician orders) for the certification period of 06/08/25 to 08/06/25. The clinical record showed no physician notifications or changes in orders. On 06/26/25 at 12:55 p.m., Staff B stated the patient should have a POC (physician orders) for the certification period. Patient #7 A review of the clinical record showed no POC (physician orders) for the certification periods of 01/14/25 to 03/14/25 and 03/15/25 to 04/16/25. The clinical record showed no physician notifications or changes in orders. On 06/26/25 at 1:10 p.m., Staff B stated the patient should have had a POC (physician orders) for the certification periods of 01/14/25 through 04/16/25. Patient #8 A review of the POC dated 03/28/25 to 05/26/25 showed orders for SN to perform monthly catheter changes using an 18 French 30 cubic centimeter catheter. The POC showed no catheter treatment intervention last changed or next due date. SN visits dated 04/03/25, 04/09/25, 04/16/25, 04/23/25, 04/30/25, 05/07/25 and 05/14/25 showed no catheter change treatment intervention was conducted. The clinical record showed no patient refusal of catheter treatment intervention, no physician notification and no changes in orders. On 06/26/25 at 1:15 p.m., Staff B stated the POC should have included catheter treatment interventions last changed or next due date for urinary catheter management. Patient #9 A review of the POC dated 05/15/25 to 07/13/25 showed orders for SN visit frequency of one time a week for eight weeks to assess health conditions and home health aide visit frequency of one time a week for one week, then two times a week for nine weeks. The POC showed no SN or CHHA goals. The clinical record showed no physician notifications or changes in orders. On 06/26/25 at 12:46 p.m., Staff B stated the POC should have SN and home health aide goals.”

“All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded in the plan of care. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure physician orders were a part of the patient’s plan of care for one (Patient #3) of nine patients. Findings: Patient #3 A review of the clinical record for certification period of 05/04/25 to 07/02/25 showed a communication note dated 05/08/25 for PT to evaluate. The clinical record showed no order transcription into the clinical record. A PT evaluation dated 05/08/25 showed no physician notification of the proposed treatment plan and no order transcription for a PT visit frequency of one time a week for one week, two times a week for three weeks, then one time a week for three weeks. On 06/26/25 at 12:46 p.m., Staff B stated the clinical record for patient #3 showed no physician order transcription into the clinical record and no physician notifications.”

“Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure: 1. SN reported the patient’s pain level outside of reporting parameters every visit as ordered for one (Patients #1) of nine patients. 2. SN reported the patient’s fasting fingerstick blood sugar level outside of reporting parameters every visit as ordered for one (Patients #2) of nine patients. 3. CHHA visit was conducted as ordered on the POC for one (Patient #9) of nine patients. Findings: Patient #1 A review of the POC dated 05/11/25 to 07/09/25 showed orders for SN to monitor the patient’s pain level every visit and report pain levels outside of the reported pain parameters of greater than 5 of 10. A SN visit note dated: · 05/27/25 showed the patient reported a pain level of 6 of 10 · 06/10/25 showed the patient reported a pain level of 7 of 10 The SN visit notes showed no physician notification and no changes in orders. On 06/26/25 at 12:40 p.m., Staff B stated the SN should have reported the patient’s pain level as ordered on the POC at the time of the visits. Patient #2 A review of the POC dated 04/25/25 to 06/23/25 showed orders for SN to monitor the patient’s fingerstick blood sugar every visit and report fasting blood sugar levels outside of the reported pain parameters of greater than greater than 150. A SN visit note dated 06/05/25 showed a fasting blood sugar level of 165. The SN visit note showed no physician notification and no changes in orders. On 06/26/25 at 12:42 p.m., Staff B stated the SN should have reported the patient’s fasting blood sugar level as ordered on the POC at the time of the visits. Patient #9 A review of the POC dated 05/15/25 to 07/13/25 showed orders for CHHA visits one time a week for one week, then two times a week for eight weeks. A CHHA visit note dated 06/17/25 showed a CHHA visit was “not started” and showed no patient refusal of CHHA visit, no physician notification and no changes in orders. On 06/26/25 at 1:25 p.m., Staff B stated the CHHA visit marked as “not started” and should have been conducted as ordered on the POC.”

“Participate in the HHA’s QAPI program; CFR(s): 484.75(b)(8) Participation in the HHA’s QAPI program; and This Element is not met as evidenced by: Based on a record review and interview, the agency failed to ensure multi-disciplined skilled professional staff were available to participate and provide input into the agency’s QAPI program for all patients and employees. Findings: A request for QAPI records for calendar years 2023, 2024 and 01/01/25 to 06/24/25 were requested. No records that showed multi-disciplined skilled professional staff participation in calendar years 2023, 2024 and 01/01/25 to 06/24/25 were provided. On 06/25/25 at 2:40 p.m., Staff A stated: 1. All QAPI program documentation was provided. 2. There were no QAPI program meeting minutes or documented activities for calendar years 2023 and 2024 and 01/01/25 to 06/24/25.”

“Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) (1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech language pathology services— (A) A registered nurse or other appropriate skilled professional who is familiar with the patient, the patient’s plan of care, and the written patient care instructions described in paragraph (g) of this section, must complete a supervisory assessment of the aide services being provided no less frequently than every 14 days; and (B) The home health aide does not need to be present during the supervisory assessment described in paragraph (h)(1)(i)(A) of this section. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure certified home health aide supervisory visits were completed every 14 days in the patients’ home for one (Patient #9) of nine patients. Findings: Patient #9 A review of a POC dated 05/15/25 to 07/13/25 showed orders for showed a CHHA visit frequency of one time a week for one week, then two times a week for eight weeks. The clinical record showed CHHA supervisory visits were scheduled for 05/27/25 and on 06/10/25. The SN visit notes dated 05/27/25 and 06/10/25 supervisory showed no aide supervision during the home visits and showed no patient refusal of aide supervision, no physician notification and no change in orders. On 06/26/25 at 1:25 p.m., Staff B stated the SN visit notes showed no in home CHHA supervisory visits were conducted.”

“Administrator appointed by governing body CFR(s): 484.105(b)(1)(i) Standard: Administrator. The administrator must: (i) Be appointed by and report to the governing body; This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure governing body appointment of the administrator for the agency in calendar years 2023 and 2024 and 01/01/25 to 06/24/25 for all patients and staff. The failed practice had the potential to effect day-to-day operational oversite responsibilities of the agency, impacting the services its patients received. Findings: A review of administrative governing body meeting minutes showed no appointment of the administrator for the agency in calendar years 2023 and 2024 and 01/01/25 to 06/24/25. On 06/26/25 at 1:45 p.m., Staff A stated governing body meeting minutes did not appoint or designate the administrator for the agency in calendar years 2023 and 2024 and 01/01/25 to 06/24/25.”

“Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient’s discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient’s care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This Element is not met as evidenced by: Based on record reviews and interview, the agency failed to ensure a completed transfer/discharge summary was provided for two (Patients #6 and #7) of nine patients. Findings: Patient #6 A review of the clinical record showed a discharge date of 02/24/25 for non-compliance. The clinical record showed no discharge summary was provided to the physician service provider. Patient #7 A review of the clinical record showed a discharge date of 04/16/25 to hospice provider services. The clinical record showed no discharge summary was provided to the physician or the hospice provider. On 06/26/25 at 1:05 p.m., Staff C stated the agency had no evidence which showed the discharge summaries were sent to the receiving service providers for patients #6 and #7.”